CT-based diagnosis in patients presenting with throat pain: A single institutional review

RATIONALE AND OBJECTIVE

To determine if patient demographic data, medical history, physical examination, and laboratory tests will help predict likelihood of imaging-based diagnosis using CT of the neck performed in the ED for a chief complaint of throat pain.

MATERIAL AND METHODS

Single institutional, retrospective review of 367 CT scans of the neck performed for the evaluation of throat pain in the ED from August 2013 to September 2019. Patients' clinical history, physical exams, lab findings, and imaging results were recorded.

RESULTS

A total of 367 CT scans of the neck performed for the evaluation of throat pain included a recorded exam and clinical history. Of these cases, we noted that the presence of cervical lymphadenopathy (OR = 2.69; 95% CI, 1.37-5.49), tonsillar findings (OR = 2.94; 95% CI, 1.4-6.57), increased white blood cell count (OR = 1.08; 95% CI, 1.02-1.15), and temperature (OR = 1.94; 95% CI, 1.1-3.6) were associated with increased likelihood of obtaining a diagnostic CT scan.

CONCLUSION

Consideration of tonsillar abnormalities, lymphadenopathy, body temperature, and measured leukocyte count prior to ordering CT scans of the neck for throat pain may increase the diagnostic yield of such exams and decrease CT utilization in the ED.

COVID-19 in cancer patients can be challenging to screen in a resource limited setting

During this COVID-19 pandemic, patients with symptoms such as fever, cough, sore throat, and coryza were advised to have RT-PCR testing for SARS-CoV-2 infection. We described here an elderly female with chronic lymphocytic leukemia, who presented with atypical symptoms that were not directly attributable to COVID-19. This patient was admitted to the non-COVID-19 ward for supportive care. Later, her chest x-ray revealed pneumonia that was confirmed to be COVID-19 by RT-PCR testing several days later. In resource-poor settings where molecular testing results suffered from delays or were altogether unavailable, the use of diagnostic imaging such as a chest x-ray could serve as a quick guide in the assessment and management of these patients especially if the imaging results suggest COVID-19 infection.

Photodynamic therapy with chlorin-based photosensitizer at 405 nm: numerical, morphological, and clinical study

Employment of chlorin-based photosensitizers (PSs) provides additional advantages to photodynamic therapy (PDT) due to absorption peak around 405 nm allowing for superficial impact and efficient antimicrobial therapy. We report on the morphological and clinical study of the efficiency of PDT at 405 nm employing chlorin-based PS. Numerical studies demonstrated difference in the distribution of absorbed dose at 405 nm in comparison with traditionally employed wavelength of 660 nm and difference in the in-depth absorbed dose distribution for skin and mucous tissues. Morphological study was performed at the inner surface of rabbit ear with histological examinations at different periods after PDT procedure. Animal study revealed tissue reaction to PDT consisting in edema manifested most in 3 days after the procedure and neoangiogenesis. OCT diagnostics was confirmed by histological examination. Clinical study included antimicrobial PDT of pharynx chronic inflammatory diseases. It revealed no side effects or complications of the PDT procedure. Pharyngoscopy indicated reduction of inflammatory manifestations, and, in particular cases, hypervascularization was observed. Morphological changes were also detected in the course of monitoring, which are in agreement with pharyngoscopy results. Microbiologic study after PDT revealed no pathogenic bacteria; however, in particular cases, saprophytic flora was detected.

[A new approach to the evaluation of the state of the microcirculatory system in patients presenting with chronic atrophic pharyngitis and treated with a synthetic neuropeptide]

This paper is devoted to the mechanisms of development of chronic atrophic pharyngitis. A method is proposed for studying microcirculation in the mucous membrane at the posterior pharyngeal wall of the patients with this condition using laser Doppler flowmetry. The role of chronic somatic pathology in the development of pharyngeal dystrophy is demonstrated. It is shown that therapy with the synthetic neuropeptide is highly efficacious for the treatment of chronic atrophic pharyngitis.

The patient with sore throat

Sore throat is a common medical complaint seen by the emergency practitioner, internist, pediatrician, and otolaryngologist. The differential for sore throat is vast. However, with a directed history this can often be narrowed down to 2 to 3 possible diagnoses. By paying particular attention to the associated symptoms and duration of symptoms, common self-limited etiologies like viral pharyngitis and nonstreptococcal tonsillitis can be distinguished from those that require more investigation, such as supraglottitis and tonsillar cancer. A sore throat is most commonly caused by an infectious, inflammatory, or neoplastic etiologic factor.

Unilateral hypopharyngitis, cellulitis, and a multinodular goiter: a triad of findings suggestive of acute suppurative thyroiditis

Acute suppurative thyroiditis is an uncommon disorder, which has been associated with pre-existing thyroid disease, especially a multinodular goiter. We describe a case of a woman who presented clinically with an acute inflammatory condition of the neck. On CT examination, she had a triad of a multinodular goiter, a unilateral hypopharyngitis, and a surrounding cellulitis. We suggest that the constellation of these imaging findings should alert the radiologist to the diagnosis of acute thyroiditis.

Pharyngitis of infectious mononucleosis: computed tomography findings

Two women presented with sore throat and fever. Their symptoms were not alleviated by antibiotics. Cervical computed tomography (CT) with contrast enhancement demonstrated enlargement of predominant posterior cervical lymph nodes and streaky heterogeneous tonsils with interspersed low attenuation. They were diagnosed as having infectious mononucleosis by their laboratory data. Thus, when radiologists encounter these CT findings of pharyngitis that is not alleviated by antibiotic therapy, infectious mononucleosis should be considered in the differential diagnosis.

Lemierre's syndrome: Porphyromonas asaccharolytica as a putative pathogen

A case of Lemierre's syndrome is reported in which metastatic abscesses resulted from septic thrombophlebitis of the internal jugular vein secondary to bacterial pharyngitis. A 32-year-old male suffering from a painful left-sided neck mass, sore throat, and fever was admitted to our hospital. Computed tomography revealed thrombosis of the left internal jugular vein, septic pulmonary emboli, and a liver abscess. Blood culture showed Porphyromonas asaccharolytica. Although empyema occurred transiently during the treatment, the patient recovered following prolonged antimicrobial therapy. Although Fusobacterium species are a well-known cause of Lemierre's syndrome, cases in whom Porphyromonas species was isolated have scarcely been reported. Moreover, case reports from Japan have been few.

Computed tomographic findings in Lemierre syndrome

Lemierre syndrome, also known as postanginal septicemia, has long been taken as an uncommon condition with life-threatening potential. It, resulting from acute oropharyngeal infection, could lead to septic thrombophlebitis of the internal jugular vein (IJV). Substantial decrease of mortality and morbidity with the introduction of antibiotics has made this syndrome into a status that is frequently forgotten or overlooked when it appears. The purpose of this article is to refresh awareness on the side of physicians of this syndrome by means of modern image tools. As such, even this dire neck infection is rare after the advent of sophisticated antibiotics, its unique computed tomography findings can facilitate the correct image diagnosis and pertinent treatment.

Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management

OBJECTIVE

We sought to describe the clinical presentation of patients with retropharyngeal abscess (RPA), utility of imaging studies, and implications on management.

METHODS

A retrospective chart review was performed at a tertiary-care, pediatric hospital with cases identified by a discharge diagnosis of RPA; posttraumatic RPA cases were excluded. Patients without confirmatory radiographic findings, fluoroscopy, or computed tomography (CT) were excluded.

RESULTS

Sixty-four cases involving 64 patients were studied. The median age of the patients was 36 months; 48 (75%) of the 64 patients were younger than 5 years. The most common chief complaints were neck pain (38%), fever (17%), sore throat (17%), neck mass (16%), and respiratory distress or stridor (5%). In 29 children (45%), it was noted that there was limitation of neck extension, in 23 (36.5%) torticollis, and in 8 (12.5%) limitation of neck flexion. The physical examination revealed stridor with wheezing in only 1 patient (1.5%) and wheezing in 1 other (1.5%). Twenty-seven patients (42%) underwent surgery; 37 (58%) were treated with antibiotics only. Performance of a surgical procedure was significantly associated with CT scan findings. Ten (37%) of 27 patients with defined abscess on CT scan were treated with antibiotics alone. There were no treatment failures in either the antibiotic-only group or the antibiotics-plus-surgery group.

CONCLUSIONS

Children with RPA present with limitation of neck movement, especially difficulty extending their neck to look up. They rarely present with respiratory distress or stridor. CT scan is useful to distinguish patients with RPA from those with retropharyngeal cellulitis. Most patients with retropharyngeal cellulitis and some with RPA can be treated successfully without surgery.

Hyperbaric oxygen (HBO2) in the treatment of Lemierre syndrome

In 1936 Lemierre described an aggressive neck infection with a high mortality rate. In the original characterization, he describes a pharyngotonsillitis and/or peritonsillar infection followed by unilateral swelling and tenderness along the sternocleidomastoid muscle owing to septic thrombophlebitis of the internal jugular vein. Subsequent to invasion and thrombophlebitis of the internal jugular vein, Fusobacterium necrophorum septicemia occurs, with rigors, high fever, and septic thromboembolism to peripheral sites, especially the lungs and bones. This entity became known as Lemierre Syndrome. Hyperbaric Oxygen (HBO2) has been described as adjunctive treatment in two cases of postanginal septicemia. This case describes the combined approach to a case of Lemierre Syndrome in which HBO2 was added as an adjunct to the treatment, with a favorable and rapid improvement in the patient's condition.

[Deep neck infections: complications of acute pharyngitis]

Deep neck infections develop as aftermath of spreading infections from an initial focus to the neighbourhood and soft tissues of the neck, through routes offering lesser resistance as fascial sheets. These cervical pictures are not numerous and generally after infective focus bad treated, linked with concomitant factors easing the rapid spread. The presence of complications as the involvement of great blood vessels, mediastin or jeopardizing the air-way may darken the prognosis, for which reason its precocious diagnosis and correct behaviour are very decisive. The paper deals with one case of neck infect, following an acute banal pharyngitis without predisposing circumstances. Follows a review of the published bibliography.

Nonsurgical management of parapharyngeal space infections: a prospective study

OBJECTIVE/HYPOTHESIS

Parapharyngeal infections, which can potentially cause life-threatening complications, may, in certain cases, be treated conservatively with no need for surgical drainage. A review of the literature reveals that the most recommended treatment of parapharyngeal infection is surgical drainage combined with intravenous antibiotic therapy. Several retrospective reports recommend conservative treatment with no surgical drainage.

STUDY DESIGN

Prospective, nonrandomized.

METHODS

A prospective study was performed on all patients with an infection limited to the parapharyngeal space.

RESULTS

Twelve patients presented with clinical and radiological diagnosis of parapharyngeal infection during a 5-year period. Five patients showed obvious presence of pus in other spaces and therefore were excluded. Seven patients with no gross extension into other spaces and with no respiratory distress or septic shock were treated with intravenous amoxicillinclavulanic acid for 9 to 14 days (average period, 11 days). All patients except one were children. All were cured with conservative management, and no surgical drainage was needed. None had any complications.

CONCLUSION

Our results confirm the effectiveness of nonsurgical treatment of infections limited to the parapharyngeal space, at least in the pediatric population.

Acute epiglottitis in the tropics: is it an adult disease?

Acute epiglottitis has traditionally been described as a paediatric disease in reports from temperate countries. There have been very few reports from tropical countries. This is a retrospective review of 32 cases of acute epiglottitis from Singapore over an eight-year period from 1992 to 1999. There were 31 adults and only one child. In Singapore, Haemophilus influenzae Type b (Hib) immunization in not routine, and thus the increased prevalence in adults cannot be attributed to Hib immunization. Eleven patients required airway intervention, of whom nine had endotracheal intubation and two had a surgical airway. Significant predictors for airway intervention included the sex of the patient, stridor, presence of airway compromise on examination and a "thumb sign" on the lateral neck radiograph. In adults, selective airway intervention is recommended as those without airway compromise at presentation recover very well with medical treatment alone.

Sore throat after central venous cannulation

Images

[Deep infections of the neck]

Infections of aponeurotic sheets of the neck are more frequent in men than in women. Its etiology although varied is basically related to infectious pharyngo-tonsillar and dental pathology. In a great deal of cases there are factors which predispose clinical manifestations or becoming complications. Early diagnosis and precocious specific treatment re-establish the normality in the majority of cases but a percentage of them resort to surgery for the condition's control.

Mesenteric lymphadenitis depicted by indium 111-labeled white blood cell imaging

An acutely ill child with abdominal pain and concomitant pharyngitis often presents a diagnostic challenge. This report describes how indium 111-labeled white blood cell imaging helped to clarify the confusing case of a 4-year-old boy with fever, pharyngitis, and abdominal pain. The triad of abnormal white cell localization in the nasopharynx, cervical lymph nodes, and right lower abdominal quadrant supported the diagnosis of a systemic infection rather than appendicitis, abscess, or another surgical condition. Mesenteric lymphadenitis associated with systemic infection should be included in the differential diagnosis of abdominal pain in a child with this clinical presentation.

[Postanginal sepsis caused by Fusobacterium necrophorum: Lemierre syndrome]

Postanginal sepsis or Lemierre's syndrome is characterised by septic thrombophlebitis of the jugular vein, metastatic abscesses in the lungs, soft tissues, joints or elsewhere, occurring several days to two weeks after tonsillitis or pharyngitis. The primary pathogen is a Gram-negative anaerobic rod, mostly Fusobacterium necrophorum. Previously healthy, young adults are affected mainly and the syndrome was seen more frequently in the pre-antibiotic era than it is nowadays. In the three young patients described here, a girl aged 15 and two boys aged 18 and 16, F. necrophorum was isolated from blood or pus. Histories and examinations were suggestive of Lemierre's syndrome. Ultrasound and CT scanning of the neck and other localisations proved to be important diagnostic tools in assessing the diagnosis. Response to therapy was slow and depended in at least one case on adequate drainage of abscesses. If the syndrome is suspected, initial antibiotic treatment should provide adequate coverage of anaerobic bacteria. In previously healthy patients with chills and fever occurring several days after a sore throat, Lemierre's syndrome should be considered.

[Significance of roentgen cinematography in the diagnosis of functional disorders of the pharyngo-esophageal junction]

Dysfunction of the pharyngo-oesophageal sphincter may escape detection by clinical examination, endoscopy, and routine barium studies. Cineradiographic examination of 300 patients with unexplained dysphagia revealed 57 cases of pharyngo-oesophageal dysfunction. In 25 cases an underlying disorder could be found, and 32 cases were considered idiopathic. Radiologically 3 types of dysfunction may be distinguished, namely late opening, incomplete relaxation, and early contraction of the pharyngo-oesophageal sphincter. Cineradiography was found to be an easy and reliable method of detecting pharyngo-oesophageal sphincter dysfunction.

[The pathogenesis of the nasopharyngeal bursa (Tornwaldt's disease) (author's transl)]

The pharyngeal recess, first described in 1842 by Mayer, is a cavity in the middle of the nasopharynx, just between the nasal septum and the ventral tuberculum atlantis. It was assumed to be an excavation of the pharyngeal mucous membrane often persistantly fixed to the embryonic spine (Chorda dorsalis). It might be therefore, looked upon as a malformation. The recess is always stuffed with mucous membrane of the pharyngeal tract and ends next to the adenoids. It might pass into the occipital bone as an epithelialized cleft surrounded by connective tissue. Cystic transformation of the recess was first described by Tornwaldt in 1885, causing discomfort in the epipharyngeal and adjacent areas, and was named Tornwaldt's disease. The clinical data of 12 patients with pharyngeal cysts are presented. The conclusion is made, that we have evident lack of knowledge between the rare clinical manifestation of the pharyngeal recess only in adults on the one hand and the almost constant presence of the pharyngeal recess in human embryos on the other. It is therefore assumed, that frequent inflammatory discharge of the nasopharynx during life initiates the development of the nasopharyngeal cyst and not vice versa.